| Since 2000, most countries around the world have achieved or committed to pursuing universal coverage, or to ensuring their populations have “access to the full range of quality health services” without financial hardship. Nations have, however, pursued different paths to that end. China, with the world’s largest health system, achieved near-universal coverage in just over a decade. In 2000, less than a third of its citizens and permanent residents had coverage; by 2011, that figure had risen to 95 percent. While China’s highly centralized political system differs from many other countries, the government’s focus on rural and unemployed residents and its targeted health infrastructure investments can offer insights for policymakers around the world. China’s Pathway to Universal Coverage By the late 1990s, China’s collective and work-unit-based health insurance systems had largely collapsed following market reforms in the 1980s and 1990s. In 1998, the government launched Urban Employee Basic Medical Insurance (UEBMI), a mandatory program for employed people financed by a payroll tax. In response to the poor performance of the Chinese health system during the 2002 SARS outbreak, the Chinese government moved to make major improvements. This was realized in 2003 and 2007, when the New Rural Cooperative Medical Scheme and Urban Residents Basic Medical Insurance were introduced to cover rural residents and urban unemployed citizens, respectively. To reduce inequities between the two groups, both programs were merged in 2016 to create Urban and Rural Resident Basic Medical Insurance (URRBMI). Today, UEBMI and URRBMI make up China’s basic medical insurance, which partially covers in- and outpatient care, primary and mental health care, pharmaceuticals, traditional Chinese medicine, and dental and eye care. Coverage grew rapidly between 2008 and 2011 through significant government subsidies for those enrolled in the two programs that now make up URRBMI, as well as massive government investment in improving primary care and public hospitals, and establishing a national essential drug list. |
| Since these coverage gains, China has seen a significant improvement in overall health outcomes, including a seven-year increase in average life expectancy, a 73 percent decrease in maternal mortality, an 86 percent decrease in child mortality, and lower rates of communicable diseases. However, China’s basic medical insurance faces some key challenges. Given China’s lower per capita income and more limited fiscal capacity compared to the United States, the government prioritizes universal baseline coverage rather than comprehensive benefits, resulting in high out-of-pocket costs — roughly a third of total health expenditures. The basic medical insurance program also has struggled to address systemic inequities between rural and urban residents. For example, the urban employed populations covered by UEBMI receive more comprehensive benefits packages, including medical savings accounts for out-of-pocket expenses. Migrant workers — who make up a fifth of China’s population — are another demographic whose coverage can be fragmented, partly because of the difficulty transferring between different insurance programs if they move to and from rural and urban areas. China also faces major challenges in health care delivery. Lacking a strong primary care system or primary care gatekeeping, hospitals are vastly overused by patients. When you add growing care utilization by China’s rapidly aging population and some people dropping coverage due to rising premiums and copayments, you get a health system under increasing pressure. In 2025, to ease some of this strain, the government announced plans to incentivize long-term enrollment by increasing government subsidies for length of time enrolled and developing long-term care insurance programs focused on older people. America’s Patchwork Health Insurance System Prior to 2010, the United States relied on a fragmented, employment-based health insurance system made up of private, largely employer-sponsored insurance and public programs like Medicaid and Medicare. It left nearly 16 percent of the population, more than 40 million Americans, uninsured. More people gained coverage following full implementation of the Affordable Care Act (ACA) in 2014, which:Expanded Medicaid eligibilityPrevented coverage denials for people with preexisting conditionsAllowed young adults to stay on their parents’ insurance until age 26Established health insurance marketplaces to purchase private plans.By 2023, the U.S. uninsured rate declined to an all-time low of 7.9 percent. However, following passage of the Trump administration’s budget reconciliation bill in July 2025 — featuring $900 billion in Medicaid cuts over the next 10 years — the U.S. is expected to return to pre-ACA highs of nearly 40 million uninsured by 2034. |
| U.S. coverage expansion relies heavily on voluntary enrollment in private plans, often with high deductibles and cost sharing, creating sizeable affordability barriers. In 2024, out-of-pocket costs increased to $1,632 per capita. For subsidized care through Medicaid or cost-sharing reductions, qualification is dependent on income and area of residence, creating variable coverage from state to state. While China structured its reforms to explicitly incorporate rural residents, unemployed urban residents, and migrant workers, U.S. coverage is hampered by the exclusion of groups like undocumented migrants and people with low incomes in non-Medicaid-expansion states. China and the United States have taken remarkably different paths to expanding health insurance coverage. The U.S. has relied on a fragmented public–private model with variable and dwindling government subsidies, resulting in persistent disparities in coverage and access — both of which are expected to only worsen in the coming decade. Meanwhile, despite a vastly different political structure to the U.S., China’s coverage gains are notable due to its massive population (nearly four times the U.S. population) and much lower per capita income. China offers a unique case study of a coordinated health insurance system designed to address disparities in access, ultimately achieving near-universal coverage in just over 10 years. |
HENRY KOTULA 